The Katrina Experiment in Medical Education

In the Fall of 2005, following hurricane Katrina, most of the New Orleans area was under several feet of water for several weeks. At this time, the senior leadership in the School of Medicine (Drs. Kahn, Krane & Dean Taylor) developed a partnership with Dr. DeBakey & the Baylor College of Medicine, who offered the use of their medical campus to allow us to "restart" our school of medicine for the next 9 months in Houston. A handful of close colleagues from different departments (Drs. Beckman, Crawford, Daroca, Johnson, Kahn, Krane, Markert, Smith & Rajan) and myself relocated to Houston in mid September to put together a 2nd year medical curriculum utilizing a mixture of faculty from Baylor, MD Anderson & Tulane. We identified and contacted available teaching faculty, developed lecture handouts, and organized the 2nd year curriculum in 2-3 week blocks, working on the next block while the current block was being delivered. BCM faculty & students utilized their classrooms for lectures & small group sessions in the morning, and we utilized them in the afternoon. We all learned to give lectures on topics outside of our normal comfort zone, but we nevertheless managed to provide "almost" the same quality of curriculum (based upon performance on both internal & standardized NBME shelf exams) that we provided for our students in New Orleans. It was an interesting educational experiment, but not one that any of us would care to repeat anytime soon.

Facilitating Student Learning Thru Lecture Recording

The average student can only transcribe 10% of the words spoken during a typical lecture. It is widely believed that having a resource for reviewing lecture content “after the fact” can aid student learning. During the summer of 2006, after returning from Houston, I worked with Niels Olson (a Naval engineer, and previous 4th year medical student) to develop a system for recording lectures to be given during the upcoming 2nd year medical curriculum. We settled upon using an Olympus digital audio recorder connected to an audio feed from the podium. Niels did the lion’s share of recording, and I created & managed a website for uploading & storing the recordings. By the end of the year this evolved into the development of a “one stop shopping” web site where lecture slides and audio files for all T2 lectures could be easily found & downloaded with little navigation involved. The following year, I began a collaboration with Bobby Garner-Coffie in the SPH/TM that allowed us to perform a pilot study using the Tegrity Classroom system for lecture capture of Med Pharm lectures. The following 2007-08 year the use of Tegrity was expanded to include recording of all T2 courses, and to a limited extent, for recording 1st year lectures. The use of the system was then expanded further to include the entire 1st & 2nd year medical curriculum, with funding provided by the SOM Deans office. In 2014 a University wide subcommittee was formed to evaluate different recording options, and shortly thereafter we switched to using Mediasite as our classroom recording platform.

Introduction of Active Learning Strategies

Just-in-Time-Teaching (JiTT) & Peer Instruction

Traditional classroom lectures are “teacher-centered” and promote passive learning. There is a growing body of evidence that indicates that active learning strategies can produce superior learning outcomes compared to traditional lectures. As a first step in implementing learner-centered / active learning strategies, in 2008-2009 we converted seven traditional Med Pharm lectures to Just-in-Time-Teaching sessions. JiTT sessions require that students complete a reading assignment & a post-reading (graded) quiz on a LMS (e.g. Blackboard or Canvas) that has a deadline the night before the class session (e.g. the LMS will close access to the quiz at midnight or 3 AM). The quiz typically contains 2 or 3 MCQs, plus a short answer essay question. The essay question asks students to reflect on the assignments learning objectives and to briefly explain “What did you find most difficult or confusing about the reading?” (a method designed to cause metacognition). These essay responses are scanned the morning before class & determine the areas to be focused on during class. Selection of previously created interactive Audience Response System (clicker) questions before class that are related to the identified areas of difficulty transforms a traditional lecture into a class session focused mainly on areas of difficulty (vs. a review of material the class already understands from their reading). Students come to class prepared with a background knowledge of the material.

When clicker questions are utilized to stimulate discussion between students, the student interaction (referred to as "peer instruction") can produce a significant increase in short term understanding (as illustrated in the poster presentation shown below)(or see a larger version).

Active Learning & Learner-Centered Instruction. Changing the Emphasis from Teaching to Learning.
Meeting of the National Directors of Graduate Studies in Pharmacology
(New Orleans, LA, April 23rd, 2009)

Small group workshop on Active Learning - National Directors of Graduate Studies in Pharmacology
(New Orleans, LA, April 23rd, 2009)

Just-in-Time-Teaching & Classroom Response Systems. Changing the Emphasis from Teaching to Learning. Annual Meeting of the Group for Research in Pathology Education (GRIPE), Jan 15, 2010. New Orleans, LA.

Team Based Learning (TBL)

The same year that I introduced JiTT into our medical curriculum, I also worked with Drs Kahn, Krane, Crawford and several other faculty to develop and introduce several sessions utilizing the Team Based Learning method (for further information, see http://www.teambasedlearning.org/). The TBL design has similarities to JiTT, but utilizes class time primarily for assessment and group exercises. During the first semester that we initiated TBL into the curriculum, I designed an exercise on Autonomic Pharmacology that includes a group exercise on identifying four different "ANS drug unknowns" based upon how they modify blood pressure responses to various agonists (ACh, NorEpi, Epi, isoproterenol, tyramine) and CV maneuvers (vagal stimulation, double carotid occlusion). I also worked with clinical colleagues over the following year to develop TBL exercises on treatment of diabetes, coagulation disorders, and heart failure. In general, replacement of didactic lectures with TBL exercises increased exam performance (internal exams & NBME standardized exams) significantly (but only by a few percent). The most marked improvement was seen in students whose grades are below the class mean (who seem to benefit the most from active learning exercises, in general).

Human Patient Simulation:

Three METI Human Patient Simulations were developed and implemented for our 2nd year medical class in 2009-2010, shortly after the opening of the Tulane Simulation Center.

The first simulation designed was focused on the diagnosis & treatment of unstable angina & cardiac arrhythmias using the adult METI Human Patient Simulator. The outline for the simulation (case history & story line) was developed by Drs Krane, LeDoux and I. Using the case outline, I developed a METI HPS scenario to emulate the patient's presenting heart rate & blood pressure, and a METI scenario for simulating the onset of unstable angina with ST segment depression & associated changes in heart rate & blood pressure. The simulation included responses to drug administration (nitroglycerin, morphine, oxygen, metoprolol), simulation of various arrhythmias (bradycardia, AV block, VTach, VFib) and treatments (Cardioversion/Defibrillation, amiodarone, lidocaine & atropine). Dr. LeDoux played the role of the ER physician, and I coordinated the simulation via a laptop computer from a control room behind a one-way mirror & played the voice of the patient "Mr. Boudreaux".

A second simulation was on the diagnosis & treatment of severe bronchoconstriction in a pediatric patient (using the 6 yo METI Human Patient Simulator). The objectives of this simulation were focused on students being able to work as a team to get the patient's history from a parent (played by a simulation staff member with a Theatre background), assess the patients status (BP, HR,RR, O2 Sat, Lung Sounds), make a diagnosis & apply treatment in the right order (O2, beta-2 agonist, steroid), followed by reassessment & ultimately "handing off" the patient to an attending physician (Scott Davis, MD - pediatrician). The simulation exercise was followed by a 30-45 min debriefing by Dr. Scott Davis. I coordinated the simulation via a laptop computer & played the voice of the patient "Wheezing Willy".

A third simulation on the treatment of severe pain was developed for the Neurology block. This simulation developed involved "Mr Tibideaux" (an alcoholic with a history of stomach ulcers) who was the victim of a gun shot wound to the leg while in a local bar. He also suffered a laceration of the area around his eye from a piece of flying glass. In the Emergency department he is evaluated by the ER physician and students. As the scenario evolves he is given morphine (vs ketorolac), suffers a morpine overdose, requires naloxone. When his eye is examined, eye pressure produces a severe bradycardia, requiring treatment with atropine. A discussion of treatment options, side effects, and drug interactions is easily covered as the scenario develops. Developed with Dr. Elma LeDoux.

To assess the educational impact of active participation in Simulation exercises, in 2011 we compared the scores obtained on two block exams for questions that were related to concepts addressed to the Sim sessions (but were also covered in lecture or self studies), vs exam scores on questions unrelated to the Sim exercises. Scores were compared for students who were present for the Sim exercise, vs those who were absent. As shown below, those who were inside the ER room during the Sim exercises significantly outperformed those who were absent, even though the same material being tested on was covered in previous lectures. A similar difference was not seen between the two groups for other exam questions. As a result, we made attendance of Sim sessions "mandatory" in the years that followed (mandatory meaning that students are given points for attendance & participation).

Medical Wikis & Interactive Self-Assessment Quizzes (Pharmwiki):

Over the past 7 years I have been developing an interactive Pharmwiki for our Medical curriculum that is designed to provide a "one stop shopping" information & learning resource for our medical & graduate students. It contains:

The Pharmwiki resource is intended to explain different systems-based topics in pharmacology topics, whenever possible in their appropriate "clinical context" in order to provide "mental scaffolding" to promote long-term retention & understanding of pharmacology. The primary philosophy in the design of Pharmwiki has been to be "correct, concise & clear". Pharmwiki has heavily emphasized the use of interactive self-assessment quizzes because educational research (conducted at different levels, from middle school to post-graduate medical education) has shown that taking frequent quizzes provides a form of "mental retrieval practice" that can produce a better recall of facts and a deeper understanding compared to an education devoid of self assessment (Dobson, 2008; Karpicke & Roediger, 2008; Logan et al, 2011; McDermott et al, 2014; Reed et al, 2014; Paul, 2015). As shown below, a 2011 survey of 2nd year medical students indicated that Pharmwiki was the #1 primary information resource for students taking Medical Pharmacology.

Related Educational Presentations & Workshops:

Wikis and Interactive Quizzes - Technology Our Students Really Use to Learn. Clarkson CW.Tulane School of Medicine Educational Technology Retreat, May 1, 2012.

GRADUATE EDUCATION:

Director of Graduate Studies in Pharmacology&
Resurrection of Our Graduate Curriculum After Katrina:

In December 2005, while I was living in Houston following Katrina, my chairman placed me in charge of our department’s doctoral and masters graduate programs. At the time of the storm we had 40 masters students and ~12 doctoral students in the pharmacology graduate program. When classes resumed at the New Orleans downtown campus in mid-January of 2006, we had 25 masters students return, along with ~ 6 doctoral students. During several trips back from my duties at Baylor, I found rooms (with acceptable air quality) that we could use for teaching in portions of the 1430 Tulane Ave building, although we tried to use the Gene Therapy conference room in the JBJ building whenever it was available. With limited access to classrooms & a reduced number of available faculty, I heavily revised our graduate curriculum, so that we could complete all previously scheduled graduate classes for the 2005-06 academic year during the Spring semester of 2006 & an extra Summer lagniappe semester in June-July of 2006. One component of this challenge was to find a way to simultaneously teach our complete Medical Pharmacology course at both the New Orleans campus (to our doctoral & masters students) & Baylor campus (to our medical students). Lectures on the two campuses had to be scheduled out of sync with each other, since our remaining teaching faculty could not be in two places at once. This was not a fun year.

Development of a Thematic & Objective-Based Graduate Curriculum (2006-07):

During the summer of 2006, in response to student criticisms about our graduate curriculum, I made a series of major changes to our department’s graduate curriculum. These changes were based upon a “proven” design – that of our 2nd year medical curriculum which I had been involved with designing over the previous decade:

I rearranged our traditional graduate curriculum to replace it with a thematic “organ-system” based design in which (as much as possible) all lectures in all graduate courses covered the same theme being covered in Medical Pharmacology. This included topics covered in our seminars & weekly journal club. This change was designed to re-inforce student learning.

With the help of our faculty, a list of specific learning objectives was developed for each graduate lecture given in our two primary graduate courses: Principles of Pharmacology & Pharmacology Research. Exams were designed to cover the material outlined in the learning objectives.

Graduate exams were placed at the end of each Med Pharm “thematic block”.

Lecture handouts, containing learning objectives, were collated prior to each thematic block & distributed ahead-of-time to students. This allowed students to prepare for lectures ahead of time.

Audio recordings of graduate lectures were initiated in the Fall of 2006 and a Graduate Resources website was developed that included the new thematic lecture schedule, and a media website was designed to provide links to down-loadable versions of all lecture audio recordings & lecture slides (html & pdf versions). One of my new duties became the development, maintainance & archieving of this website. During the 2008-09 academic year, we switched to use of the Tegrity Classroom recording system for graduate lectures, and then in 2014 we switched to using Mediasite.

Related Educational Presentation:

The Doctoral Program in Pharmacology at Tulane University – Post Katrina. Meeting of the National Directors of Graduate Studies in Pharmacology (Salt Lake City, Utah, July 25-28th, 2007 )

Systems Biology Course Directorship (2008-2012):

The Systems Biology Course was a newly constructed course, first offered in Spring 2007 for the 1st year doctoral students in our newly created umbrella “Biomedical Sciences” (BMS) doctoral program. Although this course looked great “on paper”, it received some “negative” reviews in its end-of-course survey. The major criticisms of the course included: a) some lectures were excessive in length (90+ slides), b) there was excessive redundancy & duplication of material covered in different lectures, c) there was no communication between lecturers, d) no class notes were available before lecture, e) there were too many details to be remembered for exams, and f) there were not enough exams (e.g. 2 exams was not enough).
In the Summer of 2007, I was asked by my chairman to take over as course director. After reviewing the survey results, I implemented a number of changes to address the concerns raised. These included:

Development of a course website where all lecture slides are posted in html & pdf formats (url below). This allowed myself, other faculty & students easy access to the course content. This facilitated the discovery & elimination of excessive redundancy & lecture length, prior to when classes begun in Spring of 2008.

Development of learning objectives for all lectures. These were posted on the course web site & are printed on the front cover of every lecture handout.

Redesign of the course schedule to include a 3rd exam. Each of the progress exams covers 7, 7 & 9 lectures, respectively. Exam questions are based upon the stated lecture learning objectives, so as to level the playing field of what students “need to know”.

With the assistance of Jeanne Samuel in our Office of Medical Education, we developed an online survey – feedback form (linked to from the course website) where students can provide anonymous feedback on individual lectures and exams.

For the 2009 academic year I made some additional adjustments to the course including:

streamlined the course content to focus in more depth on cardiovascular physiology & pharmacology

introduced the use of the Audience Response System for my 3 hrs of lecture. The use of the system was offered to other faculty.

began using Blackboard (MyTulane) as the Course Management System for lecture media, email communication & posting of grades

Concepts in Pharmacology Course Directorship (2008 pilot project):

To facilitate the development of active learning strategies in our graduate curriculum, I developed a 1 credit hour “pilot” course for our Masters in Pharmacology students. The course consisted of seven JiTT sessions that had a pre-class reading assignment, a pre-class Bb quiz, and a class session focused on interactive ARS questions, including 3 questions at the end of each class session using the Peer Instruction method. The course grade was based upon performance on Bb quiz questions, and Peer Instruction questions. An end of course survey indicated a high level of student satisfaction, with a 4.6 out of 5 rating for “This course enhanced my learning” (1-5 scale).

Active Learning & Learner-Centered Instruction. Changing the Emphasis from Teaching to Learning.
Meeting of the National Directors of Graduate Studies in Pharmacology
(New Orleans, LA, April 23rd, 2009)

Small group workshop on Active Learning - National Directors of Graduate Studies in Pharmacology
(New Orleans, LA, April 23rd, 2009)

Just-in-Time-Teaching & Classroom Response Systems. Changing the Emphasis from Teaching to Learning. Annual Meeting of the Group for Research in Pathology Education (GRIPE), Jan 15, 2010. New Orleans, LA.